A Private-Practice Nephrologist Talks About Her Job

Introduction

Dr. Ryan Gray: If you’re a premed and wondering how medical schools look at the new MCAT, go check out the newest Premed Years Podcast at www.MedicalSchoolHQ.net/217 where I talk to the Kaplan Pre-Health Program Executive Director, and find out what Kaplan learned from surveying medical schools.

This is the Specialty Stories Podcast, session number 6.

Whether you’re a premed or a medical student, you’ve answered the calling to become a physician. Soon you’ll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Today I have a great guest, but before that let me tell you who I am. My name is Dr. Ryan Gray, and I am the host of the Specialty Stories Podcast as well as the Old Premeds Podcast, The MCAT Podcast, and our longest running show, The Premed Years. You can check out everything that we do at www.MedEdMedia.com. That’s www.MedEdMedia.com.

This week I have an awesome guest like I mentioned before, Dr. Robey who is a private practice nephrologist. Before I go any further, let’s go ahead and dive right in and talk to her.

Dr. Jean Robey: I’m a nephrologist in private practice, my name is Jean Robey.

Meeting Dr. Jean Robey

Dr. Ryan Gray: And so you’re in private practice. What made you decide to enter private practice versus joining a community hospital or an academic hospital?

Dr. Jean Robey: Well technically speaking, nephrologists can’t really join a community hospital. The hospitals can’t subsidize everything that a nephrologist does. So a nephrologist will have a renal failure arm of service, and that renal failure arm of service needs a dialysis unit. So the hospitals at least at this time and probably in the future can’t really fund a dialysis unit and all that it may entail. So you’ll never see that, you’ll never see a nephrologist work for a hospital. Obviously the choice then is between the ivory towers of academics and private practice. And academics is wonderful. When you’re a student you just get in love with learning, and climbing those mountains, and learning more, and learning more. And many of us end up in specialties because we want to really hone in and fine tune some area of expertise. And many of the nephrologists that choose nephrology really get fascinated by nuts and bolts. So the choice to go academics is always very tempting, but academia has its own hurdles, and own demands, and requires research, and requires a commitment to research, and furthering knowledge for knowledge sake, and I was really interested in community practice, and being in the trenches. There is some setback when you do that because in academics, things come to you first. You’re the center of disaster. So complicated hard things go to you, and you get the chance to do new things, latest things, greatest things. And you’re in a circle where you’re constantly talking and having conversations that are stimulating about what’s new, what’s great, what can we try, what’s different. And when you step out of that and go to private practice, you don’t have that availability necessarily anymore, and you don’t have that knowledge- there’s a little bit of a lag, right? So there’s going to be- it’s like getting the second tier spinoff two years later. So you start to practice things that are more standardized, or have been trickled down from academia and it usually takes about two or so years. That also means you don’t end up doing things that haven’t been tried and failed, and tried and failed a lot. But in the trenches you really are just trying to push forward all of humanity. So everyone goes. It’s not just the sickest guy with the newest technology and the latest greatest, but everyone has to pull forward with some standard of betterment. And in the trenches you get a lot of patient contact which is wonderful for me, and you’re able to do a lot more of the full care of someone’s life. So in academics you kind of pop in and pop out, but in private practice you really get a chance to journey with someone, and in that journey learn what time means, and what events mean, and how things fit together in a much bigger picture. So you kind of have to like long stories and no ending, right? So that’s what brought me into private practice. Plus it brought me back locally to my home. So a lot of times when people are looking at what they’re going to do and how they’re going to do it, geography matters. And my family lives here in Arizona so it just- it was natural that I ended up here in private practice.

Dr. Ryan Gray: Okay. When did you first know that you wanted to be a nephrologist?

Dr. Jean Robey: You know that’s a great question. I did not know- and I think when I talk to students it isn’t- it’s almost like the wrong question to ask because we all are medically inclined, we all like medicine, we all see what medicine has to offer both tangible and intangible. And at some point or another we’re really looking at are we more procedure oriented, or are we sort of a thinker, and how do we like our relationships to be with our patients? I actually thought I was going to be a surgeon, so I went that route first because I liked that speed, that tempo, I liked those challenges, and I was very technical, like I liked hands on type solutions. And then I gravitated towards urology interestingly because I was interested in surgical procedures for cancer; kidney, urogenital type cancers. But I actually liked a lot that urology promised to have some still medicine attributes, so I did a year of general surgery which historically when we were trained, if you were going to go into medicine, you would do very similarly some sort of surgery type internship and then branch into medicine. Like everybody got the surgical experience, right? Because medicine 100 years ago was everything, you did everything, okay? So in a weird traditional sense, having this surgery year helped me just to understand kind of a broader scope of medicine, and then understand my colleagues on that side. And then I switched over to medicine which was a major switch. So anyone who’s ever switched from surgery to medicine or- it never goes the other way, but if you switch from surgery to medicine, there’s a big cultural switch. So now you’re in a different culture of thinking, and of interaction with patients. So once I switched to medicine, this whole other world opened up- and of course there’s adult medicine and there’s pediatric medicine, but I was doing adult medicine. And this whole other world included the breakdown of all the specialties which you’re looking at. So when you break down the specialties, there’s to me big organs and little organs, and that was an easy way to look at it. And with the big organs there’s this great physiology, and there’s this great anatomy, and they tend to be diseases- sorry specialties like cardiology, and gastroenterology, and pulmonology to some extent, but critical care is very, very heady. But then the little organs like the endocrine glands, and the autoimmune type diseases in immunology, rheumatology, nephrology, that all kinds of clumps over there because you’re looking at many, many things that don’t have moving parts, that work in bits and pieces, and nuts and bolts, and that’s how I got to nephrology. And once you figure out that you’re a big organ or a little organ guy, when you’re in the little organ world you just have to figure out what kind of diseases do you want to look at, what kind of patient care are you interested in? And for nephrology you’ve got a whole spectrum of things, but you do have this relationship with patients who have evolution of kidney failure, and then finally have kidney failure and require transplant or dialysis, and what that journey looks like. So actually my love for nephrology is not just the little nit-picks because I’m crazy about the little odds and ends, and dots, and crossing the T’s and stuff, but also these dialysis patients are absolutely precious to me. Like I love their journey, I love the fact that they have organ failure and somehow are still alive, I love that they live on something so stupid as a dialysis machine and it kind of sort of works so well that they can live decades. I love what that means for humanity that we can do that for them. So for people who are interested in even that kind of specialty, they have to have that ‘wow’ moment. That they really are a part of something that’s no short of a miracle, and amazing, and wonderful, and should just be celebrated all the time. I think a lot of the nephrologists that end up falling in love with that achievement in medicine tend to be amazing nephrologists.

Dr. Ryan Gray: Well my dad was a dialysis patient so it’s awesome that there are physicians out there like you who care so much, so thank you for that.

Dr. Jean Robey: Oh you’re welcome. I think that’s great if he was able to buy some time and enjoy some life.

Dr. Ryan Gray: How long have you been practicing?

Dr. Jean Robey: Eleven years as a nephrologist.

Traits for a Good Nephrologist

Dr. Ryan Gray: Okay. What traits do you think lead to being a good nephrologist?

Dr. Jean Robey: I think since nephrology covers this wide spectrum of looking at little things, and then looking at them away a little bit, and away a bit, and away a bit, you have to be someone who’s interested in miniscule facts to feed into larger pictures. A lot of times people will describe nephrologists as people who are advanced internists because they’re taking all the pit pieces and putting them together in this bigger picture, and figuring out how they all work together. Because kidneys are sort of bastard organs. No doubt you need one, and no doubt it’s important, but it just stays quietly in the background until- until it’s made the center. And when it is it tends to even then be a relationship, right? So people who are interested in relationships and how connections are made make an amazing nephrologist because when we go through our kidney patient’s problem list we have to take into account everything, and we have to take into account how those things interconnect with one another. If you’re a puzzle person, if you’re a story teller, if you’re excited about that kind of captain of that kind of journey, then I think you’d be an excellent nephrologist. I think you would really command the scene really well for a long time. So it’s not like you just pop in, learn all of this about a person, and then exit. That’s also got places in medicine. But if you want to keep adding to the story, keep going with that person through decades of their life and maybe their end of life, then yes, come join the rest of the colleagues that do do that. Because you’ll never meet a nephrologist that’s not interested, that that detail doesn’t matter. He’s going to log it, she’s going to account for it, they’re going to just put it all into that- they’ll prioritize it, they’ll give it different gravity, but they’ll never dismiss a detail, never. That’s the hallmark of nephrology is you have got to be obsessed with every little piece of data. And if you like that data collection translating to humanity, you’ll be so happy as a nephrologist because you’re appreciative for that trait and you’re helping someone by using those traits.

Dr. Ryan Gray: Alright I like it. What types of patients and diseases do you typically treat?

A Day in the Life of a Nephrologist

Dr. Jean Robey: So it’s a spectrum. We’ve got certainly patients who have- and I always tell patients that I’m the chemist, not the mechanic so they don’t get confused about nephrology and urology. But as the chemist I’m looking at okay, from a kidney standpoint, is your kidneys able to do what they’re meant to do, and if not, how can we help it? And is it in a good relationship with the rest of the system, the rest of the body, all the other organs? We certainly do look at patients who have stone disease, and blood pressure issues. Since the kidney is a great mecca for blood analysis, blood’s being filtered, blood’s being analyzed, that mecca can tell the body what it needs from a blood pressure standpoint, from a nutritional standpoint, from a red blood cell count standpoint, from even low metabolism standpoint. So there’s many things about the kidneys that people don’t know it’s doing, but we look at still the function of the kidney in relationship to the body. And then we of course look at patients who have kidney failure, so we end up getting patients on dialysis or patients who have had kidney transplants. So if you’re interested in that kind of medicine, there are super sub-specialties within nephrology that just do kidney transplants. There’s also sub-specialties in nephrology that are more interventional. So in the last I would say twelve years, nephrology has dared to branch out into its own procedures, and there are training programs that allow nephrologists to learn how to do interventions to specifically address fistulas and grafts, and even a few places where they’ll teach you how to create fistulas and grafts as access devices for patients on dialysis. So there is the ability to be more procedure oriented should you want to, but those are the general problems that we see and patients that we see. And they tend to be all age groups. You could go into pediatric nephrology if you wanted, and I do just adults so that’s like 18 and up. But most of my patients, because disease and kidney problems tend to occur late in life, I have a lot of older patients for sure.

Dr. Ryan Gray: Describe a typical day for you.

Dr. Jean Robey: Well in private practice it can be anything you make it. I will tell you in general there are several standard components. You’ve got your office practice, you’ve got a hospital presence, and then you’ve got your dialysis patients. And they are separate because these patients are in maintenance therapy at an outlying dialysis unit. So any nephrologist is going to have those three components, but how it’s divided up throughout the day, week or month is going to be based on their private practice, or their relationships with their partners, or their own agenda, right? So my day is interesting. I work in the largest nephrologist owned practice in America, there’s 100 nephrologists in my practice. We are a large company but we try to work philosophically like a small company. It has its own obviously challenges in doing that but in each sector we have about three to seven guys that are very intimate, so these are my local partners, and we will divvy up our duties based on the hospitals that we cover, and the patients that we cover in the community, and the dialysis units. Now the dialysis units are interesting like Circle K’s, there’s like one every five to fifteen minutes. So we might have four units in any kind of small locale, or we might have more than that. And geography matters, so like California is crazy huge, so they might drive like two hours to cover a hospital, or have an office practice once in a while or something. So I think different geographies will kind of translate into different practice, and so when- like if a student was interested and then was going to look for a job, they would have to figure out how this all fits together because invariably you’re going to have to get it all done. You’re going to have to have an office practice at one or two locations, maybe you cover a rural one. You’re going to have to have a dialysis unit or several that you round on because your patients eventually mature to renal failure. Not all of them, but some subset. And then you’re going to have to have hospitals that you cover. I cover four different hospitals and two rehab centers, and so making time for those throughout a day or a week. I can tell you my schedule because of my practice is set far, far in advance. Many nephrologists have more control and flexibility from day to day, I don’t. Like on any given calendar month I already know what I’m going to do for the entire month, I just have to make that day happen. So there’s no start and no finish, you just complete the job, right? So today is these are your duties, you just find the time to complete those duties. So I can’t really be- it’s not fair to be specific. You don’t want to know the running around, and the specifics, you just need to know that these things are the things to be done for the day, and you just wake up when you have to, and go to bed when you’re done.

Dr. Ryan Gray: Do you have to take a lot of call?

Dr. Jean Robey: Our company is very committed to maintaining a few philosophies, and one of them happens to be one every month call. This I hope will always be our philosophy because it’s so essential to the work life balance. We each take one weekend a month and we do our duty. It’s like having a tour of Vietnam, right? Like you go, you do your tour, you come out again. And so once a month we go under and then we pop back out. So the stretch for me particularly could be twelve days in a row. So you just blow through a weekend and come out the other end and then have your weekend off, and hopefully the next three weekends off, and then go back under again. So we don’t- we try very hard not to take call, and I think that’s becoming more and more so how schedules are being fashioned, because it’s sustainable. You can do that, you don’t feel like you’re dying slowly inside. Sometimes people come out and just blow their energy wad. You know they’ll just take call every other weekend and they’ll burn out within about five maybe ten years. So I don’t encourage people to just throttle it because eventually life gets a little damaged, but there’s mental fatigue and there’s physical fatigue from not just being around. So it’s nice to get into a practice and look for a practice where you can really be assured some work life balance. So we just take call once a month, and then we have some coverages that we split up. As a specialist, you know the world changed about eight years ago where we had this movement and there were hospitalists everywhere- everywhere. And the hospitalists admit, and the hospitalists discharge, and the services were all hospitalist run. So the specialist no longer admitted. It was inefficient and it was also not necessary. So the hospitalists pretty much controlled the days and nights, which means night time call is certainly not nearly as detrimental. So the hospitalists in trade for the efficiency will then cover for the hours much better, which means even if we take night call we don’t get nearly as many calls as we used to because we don’t run a service anymore, we just are consultants. So unless they have very specific nephrology questions, I think nationally we don’t get called. The hospitalists will run the show and then we’ll come in the next morning doing a regular work day. So I think that’s been a great transition for all specialists.

Work Life Balance

Dr. Ryan Gray: Do you feel like you have enough time for family for that work life balance?

Dr. Jean Robey: I think that’s an extraordinary question. We spent all of last year, at least I thought, having a lot of reflection about medicine, and what’s happening to medicine, and whether medicine is moving in the right way, or is become a bad thing, or a less desirable thing. I think it’s great if there are young people out there who are still attracted to medicine and can ignore some of this conversation. Not that the conversation is not important, and not that we aren’t trying to change what’s happening to medicine because it’s eroding a little bit, the nature of medicine, but what you ask about this reality. I will tell you medicine is not, was never meant to be, and will never be an easy road. It is not. It was meant for warriors, it was meant for survivors, it was meant for the best. I mean if we were going to recruit people, we want people to be the absolute best because they’re about to go against disease and death, and they’re about to own authority that tells other people how to go against disease and death. And I feel like when we pick as a group who’s going to come and become our doctors- not just our colleagues but our future doctors, we should tell them this is no joke, okay? And it is not going to be easy, and we can not make it easy because even if your day is short, your tasks are hard, and you will just have one patient who will devastate you, and crush you, and exhaust you. And it wasn’t that there were fifty patients, or 500 miles to drive, it was just the matter at hand was so grave. So when I look at what my life is balanced out, I say it is well worth it because I live a good life, I live a secure life; secure in what I’m able to do, and how I’m productive, and what I get back. Certainly financially I feel comfortable. And my children, they have always lived a life of compromise in that I’m often not around. I am almost always late, and there are things that certainly I miss, but there are certainly things that I make priority for. So I know my children understand that where I am and what I do is because I am lucky and I am not the one sick. And in their minds, or at least I would hope, they understand that they’ve only been asked repeatedly to take second place because someone else needs me, or needs someone, or needs something, and I need to be the one to help them do that. And so it’s the whole support system that needs to go forward. My husband understands, my children understand, and they weigh it out every day and say, ‘Yes these are sacrifices we’re willing to make.’ Now it doesn’t mean I sacrifice all of it. I mean there were certainly times when I would draw the line. Okay so we all have to draw lines, I’m not saying give it all away for free. But medicine is never going to look very fair because you have to care to wake up at 2:00 AM to take care of someone. It’s not like somebody can give you enough money, or enough respect, or enough whatever it is that you think you get paid back in, to wake up and care at 2:00 AM when it’s nothing to you. Okay? It’s not like you’re the one hurt but it’s just the right thing to do or the dignified thing to do, and you have the power to do it. You were trained, and you have the knowledge, and you have the experience. So who else would go? So when people ask me about the whole, ‘Is it still good enough?’ Or do I feel happy and balanced? I say, ‘I am grateful. I’m grateful that I have the opportunity to do this. I am grateful that I am health enough to do this. I am grateful that I have the support to do this. And I am grateful that it is being done because somewhere someone is going to benefit from just showing up, and doing my job. If we can find enough people that just want that kind of life, and that honor, then they will one day be my doctors. Like so I really feel like when we pick and choose who’s going to own this life, and all its challenges, and all its imperfections, and still say, ‘Thank you for it.’ I think it’s such a critical question and make sure we do pick those that are really ready to be a little compromised. A little uncomfortable. A little frustrated. Because certainly that happens, you know? But I think it’s fine, it’s more than fine, and I’ve thought a lot about that question because when I signed up for this podcast and I knew the topic, the question really was, ‘Would you ever tell anyone to go into medicine?’ And I’d still have to say yes I would, but I certainly would tell them be prepared. Be willing. Be able to have delayed gratification and self-sacrifice. And what I tell society is be sure. Be sure you do have something on the other end of delayed gratification. You can’t just ask people to go through the hell that they’re going to go, and training, and suffer every single day, week, and month of their life if you’re not going to give back something to those. You’re just going to treat them miserably and make them owe and never pay. That’s going to be very difficult for everyone. So I hope people still pick medicine, but it’s not a gravy train.

Nephrology Residency and Fellowship

Dr. Ryan Gray: What was the path through residency and fellowship that you had to go through to be a nephrologist?

Dr. Jean Robey: So I did a little nontraditional path, I did that one year of surgery, and then I flipped over and did medicine. And so internal medicine is three years, and then you can sit for the boards to be an internist, which also can allow you to be a hospitalist, and you can practice as a general internist. But then you can sub-specialize and nephrology tends to be either two or three years. The third year tends to be research. You can choose to do the third year or not. There’s another pathway for third year that could make you a critical care nephrologist, and although that sounds very appealing from an academic mountain climbing kind of standpoint, critical care nephrology isn’t- doesn’t translate as well into something more, because many of the hospitals have begun to hire their own critical care doctors, and they tend to be critical care pulmonologists, so critical care nephrology is more of like academic ambition rather than real practical ambition. So you do your two or three years of fellowship, and then you can sit for those boards. So it’s very similar to many specialties, we just add on another two to five years to get your specialty training.

Dr. Ryan Gray: What does a competitive applicant to nephrology fellowship look like?

Dr. Jean Robey: So this is becoming a very interesting question because as it is honestly, nephrology programs have not filled. And I think nephrology programs have not filled nationally for several reasons. Hopefully the tides will turn. But when I did my fellowship, fellowships were still very much in high demand. And here’s what’s interesting. About the time reimbursements for certain things was at an almost high, or at least around a high, they became attractive. Because I think many students naturally will look at the spectrum and say, ‘Okay it’s got to fit in here somewhere, the finances.’ And so my year when you added it all up; what you love, what you’re interested in, how you want your life to be, where you want to live, and added how much do you want to make, everyone was like, ‘Wow this really works out great.’ So there was tons of interest in nephrology. As the years go on and governmental reimbursements are constantly in jeopardy, constantly being debated and threatened, and then here this last year maybe some changes are being made. The number of people interested in that kind of commitment for that kind of potential disadvantage just wanes. I mean that makes sense, right? So you could be the most interested guy, the most committed guy, but then look at the spectrum and go, ‘There’s not going to be any money in this. This is going to be very tight.’ Okay what I have to say for that is two things. These threats- and this is just because every year I’ve gotten anxiety over it, don’t totally pan out, and they do swing. So it’ll hit a low and then people will see what happens because of this, and care, and future, and then it will swing back again I think. It has to because you just can’t suffer it for too long. So it hasn’t hit its lull yet. I actually think the number of people going into nephrology is going to drop continually because of the possible anticipation that there’s just no future financially in it, right? To pay back the commitment that you made or will make into it. So I’m saying this because when you ask me what’s a competitive nephrologist look like, I actually don’t think it’s very hard for you to get a fellowship. If you want a fellowship, just sign up and you’ll find one because they go unfilled. But it’s not that I’m not saying that competitive, you should, and historically what happened was people went into nephrology because they were thinkers and critical thinkers, and very comprehensive thinkers. They tended to be heads of departments. Like they were the kind of caliber person because of all their thinking to be extraordinary. Like the joke is that the nephrologist tends to be this mysterious highly intellectual person that is looking and thinking about things that nobody can care about and nobody can understand anyways. And certainly the joke is that the kidneys waste water than nephrologists. So we were supposed to attract the best, but what we’ve done is we’ve lost the best because we can’t promise them that life will be good, because every year the question comes up if we’ll be paying them 5% less, 20% less, whatever. It’s something that people consider unfortunately, and I’m not saying they shouldn’t, I’m just saying sometimes it’s so temperamental and so fluctuating that whatever decision you make today because of governmental changes, and comments and rumors that are happening now, won’t even be a reality by the time you’re done with your training, or by the time you’re done with your career they’ve already ebbed and flowed so much that we’re back to the good times, or close enough. So I just caution people who are very capable, very intelligent, very committed to not discount nephrology simply because when they look at the finance it just doesn’t add up. You know it’s a threat every year and as long as I’ve been in it, life is good, good enough. It’s just we don’t ever want to threaten it in that way because sometimes it can be very challenging, very tight, but overall I think people understand the complexity of medical care that we deliver is well worth the payments that we’re asking for.

Dr. Ryan Gray: Do you see any bias for osteopathic physicians in nephrology?

Dr. Jean Robey: No actually we’re actually very [Inaudible 00:33:39]. There’s a huge representation of just every nationality, and there’s a huge representation of men and women, and MD and DO. I think it’s just very totalitarian. Just show up, just be the best, just be capable of understanding complicated issues, and the equations and stuff. It’s all fine, we don’t really care who you are or how you were trained, we only care if we can talk to you and you can understand what we’re saying.

Nephrology Sub-Specialties

Dr. Ryan Gray: I like it. You mentioned a few things, but what are the opportunities to sub-specialize as a nephrologist?

Dr. Jean Robey: Right so I mean you can go into transplant nephrology, you can- even if you have this really interest in renal failure you can sort of sub-specialize in peritoneal dialysis versus home dialysis, you could do interventional nephrology to look at those accesses. For instance I’m really interested in CKD education so I do a lot of that where I talk to patients about what does this mean? Because there’s just this huge vacuum of knowledge when it comes to what the kidneys do, and what can we do to keep them healthy, and things like that. They just don’t understand the interplay between all the other disease processes so I do a lot of education. You can also as a pediatric nephrologist, you could specialize in the different arms of pediatric nephrology. I mean we have nephrologists who have sort of made themselves more distinguished by looking at autoimmune diseases, or looking at what we call nephrotic syndrome which is a very sort of sexy group of diseases that are autoimmune. So once you’re in, whatever you take interest in, you can make yourself notable for it by just declaring it. Just saying, ‘I really want to do more of these.’ And then if you’re in the right place with the right partners, they’ll just dish them over to you because there’s so much to be done, and there’s- if you’re interested there’s an opportunity there for you to grow a knowledge base based on experience. So you can just pretty much say, ‘I now want to be the go-to guy for anemia, or bone management, or for transplant. But for fellowships you would have to take an extra fellowship for transplant, or if you really wanted to do critical care nephrology, or if you wanted to do interventional you would have to take extra training for that. But again, those avenues are plentiful and within the community we all respect those that have added more formal training and informal training. It’s easy to gain our respect if you want more specialized interest, because we like that you know more about something.

What Dr. Robey Wishes She Knew Back When

Dr. Ryan Gray: Over the course of your years in practice now, looking back what do you wish you knew before going into nephrology?

Dr. Jean Robey: Oh that’s a great question. You know maybe not so fair because I’m kind of a nontraditional person. I think about things philosophically and so I really- if I was a student, and students do come to me for mentorship and stuff like that, I always tell them, ‘Listen don’t look at the details or the specifics. Really look at yourself and think about yourself, and think about what it is that you want out of your professional life.’ Because what we are- what we have in common is that we’re highly intelligent, highly motivated, and we embrace delayed gratification pretty readily. And so across the board we’ve got a bunch of over-achievers who are looking to climb mountains. And by the time they get to me and ask questions about specialties I tell them, ‘Look, I get it. I know you’re a mountain climber. Thing is, is eventually you run out of mountains to climb and you’ve got to be happy about where you’re standing and what you’re looking out at.’ So a long time ago, even before I picked nephrology, I understood that what I needed to understand eventually to live the life I was so busy creating was to like what I was looking out at and living in. So not necessarily me, but those that are looking at specialties or looking at medicine at all, just when you’re done climbing those mountains, just think, ‘If I land here and I’m doing this, am I going to like the vantage point? Am I going to like the horizon?’ If you don’t, you climbed the wrong damn mountain and it’s too late to go back, and it’s too late to try something else. Well maybe not necessarily, but you know what I mean. Like you’re not as young, and you’re not as able, and you’re not as willing anymore. But what I’m saying is, is if you ask those questions this early or early like these premed students are, it really won’t matter about the details so much. It’ll only matter if you’re done climbing mountains. Because you’ve got to eventually sit still to actually live life, and to have that family, and to have those relationships, and to watch your children grow up and stuff. So I’m in a part of my life where I’m done climbing certain kinds of mountains, and there are still some challenges here, and I still keep myself very stimulated, but in nephrology I’m happy where I’m looking out at, I’m happy what I do from day to day, and I go home, and I’m equally not a doctor. I’m equally not a nephrologist. I’m a mom, I’m a wife, I’m a friend, I’m involved in my family as a sister and a daughter, so that’s what I think people need to know long before they pick a specialty. And if I wasn’t already so philosophical I probably would say now, I wish I would have. I wish I would have just scrapped all the details and just asked, ‘When would I feel okay about not climbing another mountain?’ Because you know these people- professional students, they just keep going, and they’re never satisfied because they’re addicted to the climb. Right now I’m addicted to just looking out at what I achieved.

Dr. Ryan Gray: The view.

Dr. Jean Robey: Yeah, the view. You’ve got to want to embrace the view, you know? And have your glass of iced tea and sit down. Just sit down.

Dr. Ryan Gray: What do you wish primary care providers knew about nephrology?

Working with Other Physicians

Dr. Jean Robey: You know I love my primary care doctors. I think I’m very lucky to have collaboration with them. They’re very interested, they’re very excited. Primary care is its own beast. Those doctors tend to really like a little bit of everything, right? And they like managing a little bit of everything. And the best primary care doctors do that very well, but then also know when to involve a specialist. And it’s not like they just involve a specialist and they’re done, they’re trying to incorporate, right? So their collaboration, their eagerness to engage like that is always very fun because now we’re working a problem, and we’re both equally necessary in our own ways. And the patients have relationships with both facets, and their relationships make them whole and make them healthy. So I just want primary care doctors to know that in the right relationships, they’re essential to carry out the advice I give, to help identify problems when I can’t, to help me with the picture when it’s not as obvious or I just haven’t known the patient as long, or whatever. So it’s mostly that we’re in it together, not that I’m here to take over, or that once I’m involved they’re not necessary. It’s none of that. It’s let’s fix this problem, or let’s figure out how to make this person whole.

Dr. Ryan Gray: What are the specialties outside of nephrology and I guess primary care that you work the most with?

Dr. Jean Robey: Well that’s fascinating because just about every specialty wants to blame the kidneys for something, right? So it’s everybody. I mean I think the biggest one to be honest with you is cardiology, and that has got to be because of the relationship between heart and kidney, and the evolving recognition that cardio renal is a disease of itself just because of the balancing act. We certainly deal a lot with the endocrinologists, we deal a lot with pulmonologists because if your kidneys don’t work you might have fluid that compromises how you breathe. And then certainly diseases that fall into the autoimmune spectrum with rheumatology and immunology, we’re going to be involved with because it’s a systemic problem and it’s affecting systemic organs, and since we’re a blood filter we tend to get exposed first, or worse. You know there just isn’t any specialty that doesn’t eventually have to engage us, so it’s nice because we have a lot of collaboration and a lot of- it’s not like we’re isolated and we’re just doing our own thing. We have to be able to integrate and appreciate one another. So I mean even dermatology, even urgent care, ER, I mean we’re going to have talked to everybody at every day. So I can’t name one that I wouldn’t be working with, everybody calls us. The podiatrist calls us and says, ‘Hey I’m about to do X to the foot, can I give Y?’ Kidneys are not [Inaudible 00:44:02]. So we have a hand in everything but I think cardiology is fast becoming the most impressive relationship.

Best and Worst Parts about Nephrology

Dr. Ryan Gray: What do you like the most about being a nephrologist?

Dr. Jean Robey: I like the thinking. I think a lot. I think a lot about the science, the math, the chemistry, the psychology, the sociology. I just love thinking. And I really love where that takes me, and conversations I have with patients because of that. I think there’s so much to be had in medicine, and in human contact, that nephrology lets me go really deep, super thorough, and I get a lot out of that. I feel complete because I’ve just- I’ve looked at it all, I’ve thought about every aspect of it, and that defines my profession. So the kind of person I am, and what I get excited about has a name. It’s nephrology. And make no mistake about it, people might say, ‘Well no, it’s really not that involved.’ They just don’t even realize they’re doing it. You have to be that conscientious and that thorough to really deliver nephrology. You just can’t- I’ve never met a nephrologist that isn’t already thinking about twelve to eighteen things at once. They’re just taking all of it into account. And so what’s awesome about that is all my colleagues are like me, and that’s usually what you tell any student is, ‘Find a specialty where you’re with a bunch of friends.’ So all my colleagues are a little centric that way, they’re all kind of geeky that way, they really are excited and happy about who they are and how they do what they do. It’s an insane kind of gift to be able to juggle those many data points.

Dr. Ryan Gray: What do you like the least about being a nephrologist?

Dr. Jean Robey: Gosh I really don’t- I don’t have an instant answer to all that. It’s busy. Probably the same thing that I love about it is the thing I don’t like about it. There’s a lot to think about.

Dr. Ryan Gray: Yeah.

Dr. Jean Robey: So it can be a little exhausting at times. But you know, like my husband- I come home from work and he says- he just looks at me and he knows I’m drained. He’s like, ‘What do you do all day?’ He’s not a physician but he knows I’m not like running laps, or lifting weights, or- you know I’m like, ‘I’ve just been thinking all day.’ You know and he’s like, ‘Give me a break, how could you be this exhausted from thinking?’ So I mean I suppose that’s the one thing because there’s only a certain amount of time and you only have a certain amount of energy, and so you really spend a lot every day. But it is what it is. I wish there was more time, but that’s more of a universal complaint than that is a specialty complaint. I really hate people suffering, and my dialysis patients, they suffer quite a bit. It’s very hard to endure the kind of suffering that they have, so that I hate, but sort of still hate / love.

Dr. Ryan Gray: If you had to do it all over again, would you still choose nephrology?

Dr. Jean Robey: Oh yeah, two times at a time. There’s nothing like it for me. Like I looked at other specialties, and I looked at other nuances within the specialties, and stuff like that, and I just- I can’t explain it. I’m just really manic that way, and I like to keep busy, and there’s enough going on in nephrology that I’m never not entertained. And you know, they say this when you’re in training and stuff that you’ve got to pick the thing that’s going to challenge you for the rest of your life. That you’ll never fully understand, that you’ll never catch. Because part of the love affair is always chasing after it, right? Nephrology is funny. You can kind of get it for twenty seconds, and then you’ve got to almost relearn it. So I’m constantly like reading the same thing over and over again because it’s so ephemeral. Like my grasp of it, because there’s so many moving parts, dissipates almost the minute I understand it. So I can live like that for the rest of my life, and if I had my life to do over again, I’d want that kind of life to rejuvenate me constantly and challenge me constantly. Find that thing that you will never quite get and you will always be able to fall in love with it.

What the Future Looks Like for Nephrology

Dr. Ryan Gray: Do you see any major changes coming to the field of nephrology whether it’s technology or anything else?

Dr. Jean Robey: Well there’s two things. One kind of scary and one kind of cool. The kind of cool thing is we have this- I think in my lifetime, potential of making an artificial kidney. And it’s exciting. I get a little reserved because I don’t want to get too excited, but I think in my lifetime, because I don’t discount how technology is really booming elsewhere, we could have the ability to create intelligent tissue, and grow this tissue, and use nanotechnology to really make the artificial kidney. I think it can be done. It would take a lot of really brilliant people, a lot of collaboration, and a lot of funding, and then the practicality of it is- I don’t know, it doesn’t matter, I’m just academic about it. But you know, I think it’s a really huge possibility, okay so in the next fifty years. And then the kind of sad thing is, is so back- what, forty years ago or more, renal failure became something that people wanted to eradicate or wanted to liberate, and in doing so the government backed it and said no man left behind. And so people were funded very well. They were given special status, and special funding so that they could just be in America able to live, never denied. You know we’ve got this technology, we’re going to keep you alive, and we’re going to keep you well, and you’re going to be able to live despite. And the same thing happened with transplants to some extent, but the sad thing that I worry about is that we will sort of, I don’t know, look upon these people and say, ‘You know what? Kind of sort of moving away from this idea that will save ya’ll. Kind of sort of moving away from this idea that we can make these promises.’ And then they kind of back away support in one form or another, and justify it. So I get a little sad because in nephrology was this promise that we would be really super humane, and leave no man behind, and really give him all of the support, and try very hard to give half a million people all the support we could because they were already dead. But I don’t know, as the conversation unfolds it seems like people are able to discount them, like they’re just a number, or we overreached what we were able to do, and then they’re just slowly kind of quietly backing away from them. I feel it because I can’t deliver just right anymore. I have to be very careful, or I’m very limited what I can execute, and it feels different to me. It doesn’t feel like it used to which is I have to worry about it now. I have to weigh it out, I have to wait it out. So that to me- I hope people would just wake up and say, ‘You know if I was on dialysis, I’m already dying, I don’t want all these other barriers. You know I don’t want all these denials, I don’t want all these struggles. I might as well be dead.’ I think more so than previously a lot of people say, ‘Well you know, it’s too hard. It’s too hard to live on dialysis because there’s too many barriers.’ Well that’s sort of insult to injury so I feel bad for those patients because this new reality that we’re waking ourselves up into every single day seems to discount them, whereas before it used to really celebrate this like modern medicine miracle, right? But we’ll see what happens. I don’t think people are so inhumane, but I don’t know.

Words of Wisdom to Premeds and Medical Students

Dr. Ryan Gray: Any last words of wisdom for the premed or medical student that is interested in nephrology?

Dr. Jean Robey: Thank you for being interested in medicine still, even though you’re hearing what we’re hearing, and you’re fearing what we’re fearing. I think it’s a long road no doubt, and a challenging road no doubt, but you have to believe it is by far one of the most honorable professions ever, and will never be less than that. As far as your selection of nephrology, if you choose to join such allegiance, we’re so happy to have you; have your minds, have your influence, have your companionship, conversations. It can be incredibly rewarding to be around brilliance like yours, and I thank you because one day I may have kidney failure and I’m going to need you to be humane, and intelligent, and navigate for me some of the most complex things both socially and medically. So I really am excited for you because I think it will be forever rewarding that you’ve chose medicine and that you’re thinking and choosing nephrology.

Final Thoughts

Dr. Ryan Gray: Alright that was an amazing discussion. I’m actually going to bring Dr. Robey back on to talk more on The Premed Years Podcast because we have lots of things to talk about with her. So I hope you got some understanding of what a private practice nephrologist does, what the life of a nephrologist is, and what options are out there for you.
If you have any suggestions for topics, please let me know, Ryan@medicalschoolhq.net. If you know a physician who would be a great guest on this podcast, let me know. Let them know that they should be on this podcast. I’m always looking for new guests to bring to you here every week at Specialty Stories. I hope you enjoyed today’s episode, and as always, I hope you subscribe so that next week you’ll get the latest and greatest podcast here from us at Med Ed Media.